The patient came to clinic 13-September-2014 complaining of headache for 2 months, bifronto-occipital localization without asymmetry associated with blurred vision and attacks of blindness, vomiting and episodes of nausea with attacks of de ja vu with fainting attacks. The condition is deteriorating. MRI of the brain done 07-September-2014 showing upper stem mass of bad quality, mostly posterior third of the III ventricle.

On examination; the patient is swaying in Romberg position. There is left hemihypalgesia with weak four limbs more the left side. The deep reflexes are more brisk in the left side. SLRS was 80 degrees in the left because of weakness.  The left quadriceps is -3/5 and the right is 3/5. The mother noting that the patient is hallucinating some times.

MRI of the brain with contrast and MRA, MRV of the brain with spectroscopy and DTI were performed the same day, showing the tumor inside the posterior third of the III ventricle, pushing upward the deep cerebral veins. The tumor is multi in consistency, but not invading the surrounding structures and pushing the mesencephalon down and the basal ganglii lateral.

Midline incision over the parietal and occipital area with craniotomy to include both sides of the postero-parietal and antero-occipital area. The dura was opened parallel to the sagittal sinus from the right and reflected to left.  Interhemispheric approach without scarifying any running vein. Transcallosal approach was achieved and the deep cerebral veins identified. The tumor was highly vascular and multiconsistency and was sent to frozen section which gave the result of highly malignant astrocytoma. The tumor was attacked until the bed of the mesencephalon was seen and the right lateral ventricle was under vision. It was felt that total resection was achieved. The patient was sent for MRI, which confirmed the presence of almost 2/3 of the tumor still persisting in the left side. The patient was brought back and the left part of the tumor was removed. Both lateral ventricles and the third ventricle and the preserved deep cerebral veins were seen. Inspection of the tumor cavity was inspected. All the surrounding wall are normal brain tissue. An external drain was left to the left lateral ventricle and routine closure of the wound was achieved.

Smooth postoperative recovery. The patient was extubated immediately after surgery and she is moving all limbs with good communication, but with episodes name disorientation.

The patient was doing well. When we started to taper the Decadron, she got mutism and with difficulty got verbal response, for what we elevated the Decadron to 8 mg three times a day, after what some improvement took place.

The final histologic result was anaplastic ganglioglioma.

The patient without intraoperative MRI could be left with 2/3 of the tumor left behind. Do not ever trust your sense. Always check when you are in doubt, even when you are confident.

The patient will not need VPS since there is communication through the callosotomy site.